Questions?
We know you may have questions and we're always here to
help. You can call us any time on the phone number listed on
the back of your Aetna ID Card.
You can also send us a secure email by logging in to
www.aetnainternational.com and clicking 'Contact us'.
Claims submission made easy
This form can be used to submit a
claim for medical, dental, vision, or
pharmaceutical services.
If you're filing a claim for more than one person, a
separate form is needed for each family member.
How to Fill in this Form
Complete the entire form using black ink
Mark your answers, where applicable, with an 'X', like this: [ Double check to make sure your payment details are accurate
Sign and date the authorization
Write your member identification number on each document
submitted with your claim form
Keep a copy of your completed form for your records
Submitting your claim Once you have completed the claim form, you'll need to submit it along
with your itemized bills and receipts. If your receipts are small, you
should tape them on to a full size piece of paper. Then, submit the
documents whichever way you prefer. We will process your claim and
respond within 10 to 14 calendar days.
Upload it*
Log in at www.aetnainternational.com and click 'Claims Center'
Fax it
Outside the US: +1 877 287 1938 (via AT&T + access code)
Inside the US:+1 813 775 0195
Email it
Send attachments to [email protected] (10 MB size maximum)
Mail it
Aetna International/Aetna. PO Box 981543, El Paso, TX 79998-1543, USA
Overnight it
Attention: Aetna International/Aetna. 7777 Market Center Avenue, Suite E, El
Paso, TX 79912-8411, USA
For Claim Status or Service, Call:
Outside the US: +1 877 677 7470 (via AT&T + access code)
Collect outside the US or Direct:+1 813 775 0196
Some services may require additional information For some services, you'll need to submit
additional documents. If your claim falls into any of the
categories below, you'll need to provide the additional items
listed.
Prosthetic services (such as crowns, bridges or
dentures):
X-rays (or the dentist's narrative report, if x-rays are not available)
A dental chart showing any missing teeth and dates of
extraction
Date of prior prosthetic placement with a rationale for
replacement if applicable
Periodontal services:
X-rays
Current dated pre-operative periodontal
charting
Orthodontic services:
Date appliance was placed
Number of months of treatment
Number of months of treatment remaining
Services relating to accidental injury
Pre-treatment X-rays
Details of the accident
If your plan requires school attendance as a
condition of coverage for dependents over a
certain age, you may need to provide:
a report card, tuition statement or other form of school
attendance verification
GR-68069-9 (10-16) E General Electric R-POD
http://www.aetnainternational.com/http://www.aetnainternational.com/mailto:[email protected]
Subscribers Name (First Name, Middle Initial, Last Name/Surname) Page 1
1 Personal details About the member (subscriber) Name (as shown on your Aetna ID card including full First name)
First name(s):
Last name/Surname:
Aetna ID number (as shown on your Aetna ID card)
Date of birth Gender
M M D D Y Y Y Y Male Female
Contact details
Telephone number (include Area &/or Country Code):
Email address:
Address
Street Address:
City:
State/province:
Country:
Postal/ZIP code:
About the employer Name
General Electric
Group number
0724874
About the patient Name
First name(s):
Last name/Surname:
Date of birth Gender
M M D D Y Y Y Y Male Female
Relationship to member
Self Spouse Child Other:
2 Reimbursement details Where would you like reimbursement to be sent?
To the member (subscriber) To the provider
What payment details should we use to reimburse you?
Use the Recurring Reimbursement Election (RRE) information currently on file
Use t he information p rovided in the P ayment Details section below to establish an RRE, or update your current RRE
Use t he information p rovided in the P ayment Details sectionbelow only for expenses related to this form
How should we process your reimbursement?
By bank funds transfer from Aetna to the bank account given below. This is the easiest way of reimbursement.
By check
What currency would you like to be reimbursed with, i.e. GBP? If the currency chosen is not available for the reimbursement method selected above, we will default to a US Dollar ($) wire, if bank details are available, or a US Dollar ($) check payable to the party to which payment is sent, if no bank details exist.
Country:
Currency:
Reimbursement for Providers Outside of the U.S. If, acting reasonably, we determine that any central bank or relevant government or governmental authority imposes an artificial exchange rate (including without limitation an exchange rate which is inconsistent with the free market exchange rate) in relation to a relevant currency for any reason, we may in our sole discretion reimburse you for your valid claims pursuant to this agreement for treatment in such country in any manner we may reasonably decide. In making such determination we shall seek to ensure that, in keeping with the fundamental basis of any contract of insurance, we indemnify you for your loss (subject to the terms and conditions of your policy) but do not unjustly enrich you as may have been the case had we applied such artificial exchange rate to pay you in another currency.
Aetna In-Network Providers Outside the U.S. The manner of reimbursement may consist of payment in (i) the applicable local currency (if feasible at the sole discretion of Aetna), or (ii) if you do not have a bank account in such local currency, in the currency in which the policy premium was paid in an amount equal to that which we would have paid our network provider in the currency in which premium was paid pursuant to our obligations to such network provider (as we may reasonably determine), subject in each case to the principle of indemnity we mention above.
Out-of Network Providers Outside the U.S. The manner of reimbursement may consist of payment in (i) the applicable local currency subject to the principle of indemnity we mention above (if feasible at the sole discretion of Aetna), or (ii) if you do not have a bank account in such local currency, in the currency in which the policy premium was paid in an amount equal to the applicable Reasonable and Customary Charges.
Payment details If you have chosen to receive your benefits by bank transfer, please complete the details below. We will transfer funds to your bank at no cost to you, but we encourage you to please check with your bank to determine whether your bank may charge you any additional fees for receiving Funds Transfers.
Name of Bank Accountholder (as it appears on Bank Statement)
Bank Account number
Bank Identification Code/Routing number or Alternative ID / Code
S.W.I.F.T./BIC Code (wire only) CHIPS UID Federal ABA
Bank Sort ID IBAN* Other**
(* Please check with your bank to confirm any IBAN requirements, which, in certain countries, are mandatory and must be supplied for bank funds transfer claim payment transactions, such as in the United Arab Emirates (UAE).
** Use Other entry field to describe reported Alternative IDs or Codes such as Bank Code/Branch, RUT#, IFSC Code, KBA#
Bank details
Bank name:
Street address:
City:
State/province:
Country:
Postal/ZIP code:
Telephone number (include Area &/or Country Code):
GR-68069-9 (10-16) E General Electric Please Retain A Copy For Your Records
Subscribers Name (First Name, Middle Initial, Last Name/Surname) Page 2
3 Claim details What type of service(s) are you filing a claim for? Refer to your plan documents to verify the coverage(s) that are available through your Plan.
Medical Pharmacy Dental - please attach form GC-14423 Vision
(Identify the related tooth number for all dental procedures)
Respond Yes or No
The claim is related to a work related accident or condition. Yes No
The claim is related to an accidental injury. Yes No
If you're submitting a claim for a work-related accident or condition, or an accidental injury, please give the details:
Date of accident Time
M M D D Y Y Y Y H H M M AM PM
How and where did the accident occur?
Please note: Use the space below to summarize each instance of treatment youre filing a claim for. If you need to submit a claim for more than two instances, please also complete Page 3 and return it along with this form.
Check here if only the Treatment Summaries below are included for this claim submission.
Treatment summary
Treatment date Total charge (with currency)
M M D D Y Y Y Y
Location of claim Providers name and address
City:
State/province:
Country:
Postal/ZIP code:
Description of service
i.e. type of treatment, name of medication/device
Reason for visit
Type of patient
Inpatient Outpatient
If in patient...
What was the admit date?
